Pleural Effusion, etiology, investigations and management

1. PLEURAL
EFFUSION
Dr.S.Sesha Sai (MD),
Pulmonary Medicine

2. Overview
• Introduction
• Classification
• Pathogenesis
• Etiology
• Clinical features
• Investigations
• Management

3. • Pleural effusion is defined as abnormal
accumulation of fluid in the pleural
space, i.e., the space between parietal
and visceral pleura
• The pleural space contains normally
0.3ml/kg body weight of pleural
fluid1. There is a continuous circulation
of this fluid and the lymphatic vessels
can cope with several millilitres of extra
fluid per 24hours
• Fluid accumulates in the pleural cavity
due to either altered hydrostatic and
oncotic pressures or altered
permeability of the pleura
Introduction

4. More Definitions ?
• Parapneumonic Effusion : pleural effusion associated
with bacterial pneumonia, bronchiectasis, or lung
abscess .
• Loculated Effusion : Fluid anatomically confined and
not freely flowing in the pleural space when there are
adhesions between the visceral and the parietal
pleura .
• Sub-Pulmonic Effusion:accumulation of fluid between
the lung & the diaphragm which gives the false
impression of an elevated hemi-diaphragm

5. Pleural Effusion Parapneumonic effusion
Loculated Effusion Subpulmonic Effusion

6. Composition of pleural fluid
• Clear ultra filtrate of plasma
• Volume
• Cells/ mm3
0.3 mL/kg
1000 – 5000
60%
30%
5%
5%
1-2 g/dL
<50% plasma level(105-333IU/L)
 plasma level(90-120)
≥ plasma level(7.6-7.64)
• Mesothelial cells
• Monocytes
• Lymphocytes
• PMN’s
• Protein
• LDH
• Glucose
• pH

7. •Can be unilateral or bilateral and classified
A)Based on site
Apical
Interlobar
Sub-pulmonic
Mediastinal
B)Based on mechanism and type of pleural fluid
Transudative (alteration in hydrostatic and oncotic pressure)
Exudative (alteration in pleural permeability)
Classification

8. c) Based on mechanism and type of pleural fluid
formed
Pyogenic
Chylous
Haemothorax
Pseudochylous
Hydrothorax
Urinothorax

9. Transudative pleural effusions
Alteration of hydrostatic and oncotic factors
that increase the formation or decrease the
absorption of pleural fluid (e.g., increased
mean capillary pressure [heart failure] or
decreased oncotic pressure [cirrhosis or
nephrotic syndrome]).

10. Exudative pleural effusions
Damage or disruption of the normal pleural
membranes or vasculature (e.g., tumor
involvement of the pleural space, infection,
inflammatory conditions, or trauma) leads
to increased capillary permeability or
decreased lymphatic drainage.

11. Pathogenesis
• Increased vascular permeability allows migration of
inflammatory cells (neutrophils, lymphocytes, and eosinophils)
into the pleural space.
• The process is mediated by a number of cytokines such as
interleukin IL-1, IL-6, IL-8, tumour necrosis factor (TNF)-alpha and
platelet activating factor released by mesothelial cells lining the
pleural space. The result is the exudative stage of a pleural
effusion. This progresses to the fibro-purulent stage due to
increased fluid accumulation and bacterial invasion across the
damaged epithelium.
• Neutrophil migration occurs as well as activation of the
coagulation cascade leading to pro-coagulant activity and
decreased fibrinolysis. Deposition of fibrin in the pleural
space then leads to septation or loculation. The pleural
fluid pH and glucose level falls while LDH levels increase.

12. Etiology
• EXUDATIVE
 Infective: Pneumonia, Bronchiectasis, Pancreatitis, TB, Lung
abscess
 Collagen vascular disease: SLE, Rheumatoid arthritis, Polyarteritis
 Neoplastic: leukemias and lymphomas
 Uremia
 Drugs: Bromocriptine, amiodarone, nitofurantoin, dantrolene, INH,
PAS
 Postradiation
 Traumatic

13. • TRANSUDATIVE:
Renal cause: Nephrotic syndrome
Cardiac cause: Congestive cardiac failure
Hepatic cause: Hepatic failure
Nutritional: Protein energy malnutrition
Hypothyroidism

14. • PYOGENIC:
Lung abscess
Septicemia
Chest wall injuries
Rupture of oesophagus
Rupture of subphrenic abscess
Rupture of liver abscess

15. • CHYLOUS:
Trauma to thoracic duct
Tumour (mediastinal lymphoma)
Tuberculosis
Lymphatic obstruction

16. • HEMOTHORAX:
Chest wall injuries
Bleeding disorders
Neoplasms-leukemias, lymphoma, mesothelioma
Drugs-anticoagulants
Pulmonary infarction

17. • PSEUDOCHYLOUS:
Rheumatoid pleuritis
Tuberculosis or paragonimiasis(lung fluke infection)
• HYDROTHORAX:
Congestive heart failure
Hepatic & Renal failure

18. Clinical Presentation
 The underlying cause of the effusion usually
dictates the symptoms, although patients may be
asymptomatic.
 Pleural inflammation, abnormal pulmonary
mechanics, and worsened alveolar gas
exchange produce symptoms and signs of
disease.

19. Symptomsand signs
 Inflammation of the parietal pleura leads to
pain in local (intercostal) involved areas or
referred (phrenic) distributions (shoulder).
 Dyspnea is frequent and may be present
and out of proportion to the size of the
effusion.
 Cough can occur.

20. Physical examination
Inspection:
Absent or diminished movements of affected side
 Fullness of chest with bulging intercostal spaces
Palpation:
 Diminished breath sounds over the site of the effusion
Decreased or absent tactile fremitus
Percussion:
 Stony dullness to percussion
Auscultation:
 Absence of breath sounds over the effusion
 Vocal resonance absent
 Signs of pneumonia like bronchial breathing, crackles etc.

21. Investigations
 Total and differential leucocyte counts
• Acute phase reactants-white cell count, total neutrophil
count, CRP, ESR, pro-calcitonin distinguish bacterial from
viral causes
 Radiological examination
• X-ray chest PA view done in erect position-a total of
300mL of fluid is needed to diagnose pleural effusion
clinically and radiologically
• Even 50mL of fluid can be demonstrated radiologically in
lateral decubitus

22. Findings
• Obliteration of cardiophrenic and costophrenic angles
• Loculated effusions
• Subpulmonic effusion-collection of fluid below the
diaphragm will lead to elevation of diaphragm, confirmed
by X-ray in lateral decubitus
• Lateral decubitus on side of effusion will show a shift in
the fluid level
• Tracheal and mediastinal shifts are seen in massive
effusion

24.  Ultrasonogram
Useful in differentiating between loculated pleural effusion and tumour
 CT Scan
Helpful if the effusion is minimal or loculated
 Pleural fluid aspiration (Thoracocentesis)
Diagnostic: Helps to differentiate between exudates and transudates
Therapeutic: Massive collection or rapid collection of pleural fluid
Severe respiratory distress
Suspected empyema
Massive mediastinal shift

25. Gross appearance
• Straw-coloured
• Blood stained
• Purulent
• Chylous

26. Transudate & Exudate
Features Transudates Exudates
Appearance Clear/Straw coloured Cloudy, purulent,
opalascent
Protein < 3g/100mL >3g/100mL
pH >7.2 <7.2
Glucose >40mg/dL <40mg/dL
LDH Low, <200IU/L High,>200IU/L
Cells <1000/mm3 >1000/mm3

27. LIGHT’S CRITERIA:
• Atleast one of the following criteria should be
satisfied to identify exudates:
Pleural fluid to serum total protein ratio- more than
0.5
Pleural fluid to serum LDH ratio- more than 0.6
Pleural fluid LDH- more than two-third of serum LDH
None of these criteria should be satisfied in a
transudative effusion

28. Pleural fluid appearance
• Most transudates are clear, straw colored,
nonviscid, and without odor
• Red-tinged pleural effusions indicate the
presence of blood.

29. Bloody pleural fluid
• If the blood is due to thoracentesis, the degree of
discoloration should clear during the aspiration.
• Bloody pleural fluid usually indicates the
presence of malignancy, pulmonary embolism
(PE), or trauma.

30. Hemothorax
• The presence of gross blood should lead to
the measurement of a pleural fluid
hematocrit.
• Hemothorax is defined as a pleural fluid to
blood hematocrit ratio of >0.5, and chest tube
drainage should be considered.

31.  Eosinophilia (>10% of total nucleated cell count) is
suggestive of air or blood in the pleural space. If
air or blood is not present in the pleural space,
consideration should be given to fungal and
parasitic infection, drug- induced disease, PE,
asbestos-related disease, and Churg-Strauss
syndrome.

32. • Lymphocytosis (>50% of the total nucleated
cell count) is suggestive of malignancy or
tuberculosis.
• Mesothelial cells argues against the
diagnosis of tuberculosis.
• Plasma cells suggest a diagnosis of multiple
myeloma.

33. Glucose concentration
A glucose concentration of <60 mg/dL is
probably due to
 tuberculosis,
 malignancy,
 rheumatoid arthritis, or
 parapneumonic effusion.
For parapneumonic pleural effusions with a
glucose of <60 mg/dL, tube thoracostomy
should be considered.

34. Pleural fluid with a low pH
A pH of <7.3 is seen with
• empyema,
• tuberculosis,
• malignancy,
• collagen vascular
disease, or
• esophageal rupture.

35. Amylase
• An elevation of amylase suggests that the
patient has pancreatic disease, malignancy,
or esophageal rupture.
• Malignancy and esophageal rupture have
salivary amylase elevations and not
pancreatic amylase elevations.

36. Turbid or milky fluid
After it is centrifuged.
• If the supernatant clears, the cloudiness is likely due to
cells and debris.
• If the supernatant remains turbid, pleural lipids should be
measured. Elevation of triglycerides (>110 mg/dL)
suggests that a chylothorax is present, usually due to
disruption of the thoracic duct from trauma, surgery, or
malignancy (i.e., lymphoma).

37. Cytology
 Cytology is positive in approximately 60% of
malignant effusions.
 The volume of pleural fluid analyzed does not
impact the yield of cytologic diagnosis.
 Repeat thoracentesis increases the
diagnostic yield.

38. Urinothorax
Due to obstructive uropathy
Urine arrives in the pleural space either
retroperitoneally under the posterior
diaphragm, or via the retroperitoneal
lymphatics
Pleural fluid smells of urine.
Pleural fluid Creatinine ≈ Serum Creatinine

39. Other investigations
• Suspected TB
• Adenosine deaminase (> 50
IU/L)
• Beta2 - microglobulin
• Lysozyme III (> 20mcg/mL)
• PCR (Sens 100%, Spec
95%)
• AFB (smear 10-20%; cx 25-
50%)
• Suspected Rheumatoid
• Pleural RF
• Low glucose
• Suspected SLE
• Serum Complement
• Pleural ANA
• LE cells
• Suspected Pneumonia
• pH
• Suspected
Pancreatitis
• Pleural Amylase

40.  Pleural Biopsy
• Can be done at maximum dullness on percussion or
at a maximum thickening of pleura. Abram’s pleural
biopsy needle is used for biopsy
• Most helpful in evaluating for TB
• Limited utility for CA (40-50% positive)
Repeat cytology x 3
• Sarcoid, fungal: might be helpful

41. Management
SUPPORTIVE TREATMENT
• Oxygen is necessary if SpO2 <92%
• Fluid therapy if child dehydrated or unable/unwilling
in drinking water
• Initiate IV antibiotics
• Analgesics and antipyretics
• Chest radiography & U/S

42. Medical
• Treat the cause
Pneumonia- initial antibiotic treatment
A) Following community acquired pneumonia
• Cefuroxime
• Co-amoxiclav
• Penicillin & flucloxacillin
• Amoxicillin & flucloxaxillin
• Clindamycin
B) Hospital acquired pneumonia
• Broader spectrum antibiotics that cover aerobic gram negative rods

43. • Tuberculosis- Category I treatment
2HRZE+4HRE
Prednisolone 1-2mg/kg orally 4-6weeks promotes
rapid absorption of the pleural fluid and prevents
fibrosis
• Congestive cardiac failure- treat with diuretics and
other anti-failure medications

44. Surgical
• Pleural fluid aspiration is done by using a wide bore
needle. If the fluid is thick and cannot be drained by a
needle, an intercostal drainage(under water seal) at the
most dependant part should be done.

45. Tube Thoracostomy
•Pneumothorax
•Pleural fluid loculated
•Recurrent Pleural effusion - malignancy
•Effusion filling more than half the hemithorax
•Air fluid level – Hydro/Pyopneumothorax
•Pus in the pleural space - Empyema
•Hemothorax/Chylothorax
•Para pneumonic effusion
oPositive stain for microorganisms
oPositive pleural fluid cultures
oPleural fluid pH <7.2
oPleural fluid glucose <60 mg/dL

46. Underwater seal bag is used as one way valve mechanism.
The air or fluid/pus from the pleura enters the underwater
drainage bag, but the atmospheric air cannot enter pleura due
to under water seal

49.  Failure to drain with a single small-bore tube
should also lead to thoracic surgery consultation to
avoid delays in case video assisted thoracoscopy
(VATS) becomes necessary.
VATS

50. Chemical pleurodesis
Chemical pleurodesis is an effective therapy for
recurrent effusions. This treatment is recommended
in patients whose symptoms are relieved with initial
drainage but who have rapid reaccumulation of fluid.
Talc slurry - Effective and inexpensive.
Doxycycline or minocycline can also be instilled
into the pleural space via a chest tube.
Pain is more prevalent and severe following
doxycycline and minocycline than following talc.

51. Chronic indwelling pleural catheters
 Provide good
control of
effusion-related
symptoms via
intermittent
drainage.

52. THANK YOU